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331 Cards in this Set
- Front
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The FAST examination isparticularly useful for what type of patients
27:299.4;p1 |
1. are too hemodynamically unstable to leave the ED for CT scanning;
2. have a physical examination that is unreliable secondary to drug intoxication, distracting injury, or central nervoussystem injury. 3. have unexplained hypotension and an equivocal physical examination |
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FAST examination had a sensitivity of what and a specificity of what and accuracy of what
27:299.4;p2 |
FAST examination had a sensitivity of 90%, specificity of 99%, and accuracy of99%
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What is a common site for blood to accumulate when any solid intra-abdominal organ has been injured?
27:299.4;p2 |
Morison's pouch, the potential space between the liver and right kidney, is a common site for blood to accumulatewhen any solid intra-abdominal organ has been injured.
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Why is it essential to visualize the left diaphragm andleft subphrenic space during a FAST exam?
27:299.4;p5 |
Because the splenorenal recess is not the most common site forfree intraperitoneal fluid to accumulate in the left upper quadrant
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What is the most dependent area of the peritonealcavity?
27;299.4;p6 |
Free intraperitoneal fluid often accumulates in the pelvis
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When comparing the FAST examination and the chestradiograph with the criterion standard definitions, both diagnostic tests had what sensitivity, specificity, and accuracy for detecting pleural fluid?
27;299.4;p11 |
When comparing the FAST examination and the chestradiograph with the criterion standard definitions, both diagnostic tests had an equal sensitivity (96.2%), specificity(100%), and accuracy (99.6%) for detecting pleural fluid.
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What are considered normal signs on ultrasound when looking for a pneumothorax?
27;299.4;p13 |
Lung sliding and comet tail artifact
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A screening bedside US examination can now be obtained on patients >50 years of age who presentwith pain in the abdomen, back, flank, or groin and in those who present with dizziness, syncope, unexplainedhypotension, or cardiac arrest. What are we looking for?
27;299.4;p15 |
Abdominal Aortic Aneurysm
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Most patients with an AAA are asymptomatic until rupture occurs, and the mortality rate is what?
27;299.4;p15 |
The overall mortality for ruptured AAA is roughly80%
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What is the primary abnormality found on aortic Ultrasound?
27;299.4;p16 |
The primary abnormality is aneurysmal enlargement of the abdominal aorta. This is most frequently seen in thetransverse view as an aorta >3.0 cm in diameter. More than 90% ofAAAs occur in the distal abdominal aorta, inferior to the renal arteries
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What is the primary goal of emergency sonography of the pelvis in the first trimester?
27;299.4;p19 |
The primary goal of emergency sonography of the pelvis in the first trimester is to identify anintrauterine pregnancy, which essentially excludes the diagnosis of ectopic pregnancy.
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Transvaginal sonography can establish a diagnosis of intrauterine pregnancy or ectopic pregnancy in what percent ofpatients at the time of their initial presentation?
27;299.4;p22 |
Transvaginal sonography can establish a diagnosis of intrauterine pregnancy or ectopic pregnancy in 75% ofpatients at the time of their initial presentation.
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What is the discriminatory zone?
27;299.4;p24 |
The discriminatory zone is the -hCG level above which an intrauterine pregnancy should be consistently visualized by pelvic sonography. Patientswith a -hCG level above the discriminatory zone who do not have an intrauterine pregnancy on US examination arepresumed to have an ectopic pregnancy until proven otherwise.The discriminatory zone -hCG level of 1000 mIU/mL waschosen because this is the level above which an intrauterine pregnancy can be consistently visualized bycomprehensive transvaginal sonography.
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An "indeterminate" US examination in early pregnancy demonstrates no signs of intrauterine pregnancy or anectopic pregnancy-what should you do when for this?
27;299.4;p24 |
Emergency physicians should obtain a comprehensive US examination if no intrauterinepregnancy or ectopic pregnancy is identified with emergency bedside sonography
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What are nonspecific sonographic findings of an Ectopic pregnancy?
27;299;p24 |
Any free pelvic fluid 52%
Complex pelvic mass 75% Moderate or large free pelvic fluid 86% Tubal ring(early diagnostic) >95% Mass and free fluid 97% Hepatorenal free fluid 10% |
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What percentage of patients with acute cholecystitis have gallstones?
27;299.4;p46 |
Ninety-five percent to 99% of patients with acute cholecystitis have gallstones.
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The sonographicMurphy sign (pain elicited by pressing over the fundus of the gallbladder with a US probe) may be present in what percent of patients with acute cholecystitis?
27;299.4;p28 |
The sonographicMurphy sign (pain elicited by pressing over the fundus of the gallbladder with a US probe) may be present in 98.8%of cases but is not by itself specific for cholecystitis.
The sensitivity of the sonographic Murphy sign forcholecystitis was 75% for emergency physicians performing the test at the bedside compared with 45% for theformal US examination |
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Ninety-two percent of patients with cholecystitis will have a thickened gallbladder wall of what size?
27;299.4;p31 |
Ninety-two percent of patients with cholecystitis will have a thickened gallbladder wall >3 mm. The mean gallbladder wall measurement in patients with acutecholecystitis is typically 9 mm. For cases of chronic cholecystitis, the mean measurement is 5 mm
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This occurs when thegallbladder is contracted around many stones, with most of the bile emptied?
27;299.4;p31 |
The wall echo shadow sign is commonly seen in gallstone-filled gallbladders and consists ofan anterior echogenic line arising from the near wall of the gallbladder, an intervening anechoic stripe generatedfrom bile, when present, and a posterior brightly echogenic line representing stone material followed by a prominentposterior acoustic shadow
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Familiarity with the sonographic appearance of cellulitis is important for what two reasons?
27;299.4;p36 |
First, arim of cellulitic tissue nearly always surrounds an abscess cavity, and second, cellulitis is the usual diagnosis ofexclusion when performing US on an undifferentiated skin and soft tissue infection. Findings include: thickened and abnormally hyperechoic skin, swelling and diffusely increasedechogenicity of the subcutaneous tissue, and areas of hypoechoic edema that traverse the subcutaneous fat in areticular pattern.
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In general, is bedside ED US recommended for diagnosing DVT limited to the calf or ankle?
27;299.4;p39 |
No.Success rates can beas low as 40% even for experienced vascular technologists. Near-complete compression of the vein is not sufficient to exclude DVT. The lumen of the vessel must disappearcompletely to exclude the presence of a clot. It is imperative to keep in mind that moderate- andhigh-risk patients who require a lower extremity US to exclude a DVT should have a repeat scan in 5 to 7 days
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What are advantages and limitations of CT?
27;299.2;p1 |
The advantages of CT include availability, rapid acquisition of images, and lower cost compared withMRI. The major limitations of CT are significant radiation exposure and the inability to use IVcontrast in patients with renal insufficiency or significant allergy to contrast.
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T1-weighted images are often thought of as "anatomy" scans because why?
27;299.3;p5 |
T1-weighted images are often thought of as "anatomy" scans because they clearly delineate the boundaries between different tissue planes. Fluid is very dark, solid organs and muscles are gray, and fat (including fatty bone marrow) is very bright. T1-weighting is also chosen for contrast-enhanced scans because gadolinium, the most common MRI contrast agent, appears bright, owing to its T1 shortening effect.
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On T2-weighted images, fluid is very bright, while most other tissues are gray or dark. Such images are often thought of as "pathology" scans because why?
27;299.3;p5 |
T2 weighted images are often thought of as "pathology" scans because abnormal fluid collections and edematous tissue are bright against the darker background of normal tissueWith contrast-enhanced and T2-weighted sequences, abnormal tissue is made even more conspicuous by suppressing the background fat signal using either chemically selective fat saturation pulses or (in combination with T2-weighting) inversion recovery sequences.
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Due to its superior contrast resolution, what has a distinct advantage over CT in the workup of spinal cord compression, whether caused by metastatic disease, trauma?
27;299.3;p7 |
MRI. CT myelography can also delineate the lesions associated with cord compression, but carries additional risks of patient discomfort, secondary infection, bleeding,
contrast reaction, and exacerbation of compression by the removal of cerebrospinal fluid. |
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In traumatic myelopathy, MRI and CT are complementary; plain films or CT will characterize fractures and potentially suggest spinal cord injury, but is MRI better?
27;299.3;p7 |
MRI allows direct characterization of spinal cord involvement, from edema to hematoma to complete transection.
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MRI, in combination with what, is an excellent test for suspected cerebral venous sinus thrombosis?
27;299.3;p12 |
MRI, in combination with magnetic resonance venography, is an excellent test for suspected cerebral venous sinus thrombosis. Noncontrast head CT may show a "delta sign" created by thrombus in the superior sagittal sinus or a "cord sign" from thrombosed cortical veins, whereas a contrast-enhanced CT may show a "negative delta sign" from enhancement of the dural leaves around the thrombus.
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Why is MRI superior to CT for venous sinus thrombosis workup?
27;299.3;p12 |
MRI offers greater sensitivity and is able to distinguish clot from normal blood in the venous sinus and to show enhancement of the vessel walls surrounding the clot.
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MRI with what accurately diagnoses dissection of the carotid?
27;299.3;p13 |
MRI with MR angiography (MRI/MRA) accurately diagnoses dissection of the carotid and vertebral arteries7,8 and has become accepted as the noninvasive alternative to conventional contrast angiography, which carries attendant risks of embolism, bleeding, and adverse effects of iodinated contrast. Furthermore, although angiography seeks to find the typical luminal abnormality of a dissection, MRI/MRA directly visualizes the intramural thrombus (by detecting the methemoglobin within the hematoma) and provides information about the extent of the dissection and associated ischemic injury to the brain
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MRI has been shown to be what to CT in detecting acute hemorrhagic stroke?
27;299.3;p14 |
MRI has been shown to be equivalent to CT in detecting acute hemorrhagic stroke, BUT is better at visualizing the posterior fossa, and offers increased sensitivity for detecting acute ischemic stroke, particularly with diffusion-weighted imaging protocols, which can detect abnormalities in brain parenchyma due to ischemic injury within minutes.
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It is the appropriate second diagnostic step when US is nondiagnostic or unavailable for a pregnant patient who may have appendicitis.
27;299.3;p19 |
Noncontrast MRI
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Soft tissue injuries, including muscle tear, tendon or ligament disruption, nerve damage, hemorrhage, inflammation, and edema, are best diagnosed with what study?
27;299.3;p25 |
MRI and is also the best imaging choice in patients with suspected disk herniation and radicular symptoms severe enough to be disabling and require surgical intervention
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A host of other metal-containing devices and foreign bodies are susceptible to migration or heating during MRI and present what type of contraindications to MRI?
27;299.3;p33 |
Absolute contraindications. Certain types of cerebral aneurysm clips may become dislodged and lead to hemorrhage. Cochlear implants may be damaged and may cause injury due to eddy current heating effects. Programmed devices, such as neurostimulators and bone growth stimulators, may malfunction in the presence of high magnetic fields and may lead to injury due to overheating or electrical currents.
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Regarding MRI, Clinicians must also consider the presence of what?
27;299.3;p34 |
the presence of metallic foreign bodies that patients themselves may not be aware of. Small steel slivers embedded in the eye, occasionally seen in asymptomatic sheet metal workers or welders, can injure the retina and cause blindness; when occupational history suggests the possibility, a plain film of the orbits may be obtained to search for evidence of retained metal.
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The known adverse effects of MRI are related to what?
27;299.3;p35 |
The use of gadolinium-based contrast agents. Allergies do occur, mostly in patients with a history of asthma and multiple allergies.
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MRI with contrast traditionally has been used as the alternative cross-sectional study for patients with renal insufficiency who cannot receive iodinated contrast for a CT scan. However, there is evidence that gadolinium also may lead to what?
27;299.3;p35 |
A contrast nephropathy, particularly when
delivered at high doses.35,36 Contrast-induced nephropathy due to standard doses of gadolinium- based agents, however, remains unlikely. |
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The U.S. Food and Drug Administration has issued a warning for practitioners regarding the use of gadolinium-based contrast agents in patients with what?
27;299.3;p35 |
Patients with acute renal failure or chronic severe renal
failure. |
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Gadolinium-based contrast should OR should not be administered to a pregnant patient unless it is clearly indicated, and only after the patient has been informed about the potential risks?
27;299.3;p35 |
Should not-duh
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In a typical helical scanner, how many images can be acquired in 1 minute or less, which requires less breath-holding (often just once) and thus less likelihood of slice misregistration?
27;299.2;p10 |
In a typical helical scanner, 60 images can be
acquired in 1 minute or less, which requires less breath-holding (often just once) and thus less likelihood of slice misregistration. --When a patient breathes to different depths with each slice, lesions as large as 1 cm can be missed as a result of slice misregistration |
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Helical CT scanning has optimized the delivery of IV contrast. The rapid speed of the scanning
technique allows for what? 27;299.2;p12 |
Helical CT scanning allows for much finer control over which phase of IV contrast enhancement is imaged and allows for the possibility of obtaining more information from a single bolus of contrast.
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The faster data acquisition capability of WHAT? has enabled even more specialized contrast examinations, including early and late arterial phases, parenchymal phase, and delayed phase after a bolus administration of IV contrast.
27;299.4;p13 |
multidetector CT (MDCT). The faster data acquisition capability of MDCT has enabled even more specialized contrast examinations, including early and late arterial phases, parenchymal phase, and delayed phase after a bolus administration of IV contrast. The use of MDCT for imaging the thoracic aorta, for example, typically will result in superior image quality because the scans are usually acquired with a narrower section thickness and in a shorter period.
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Radiation burden should always be considered when deliberating the risks and benefits of the various imaging modalities, and this is of particular concern with the MDCT scanners.
27;299.2;p15 |
MDCT scans do not fundamentally alter the radiation dose when compared with helical CT. However, when thinner slices are acquired, the radiation dose must be increased to maintain a favorable signal-to-noise ratio. Radiation exposure is increased with MDCT and is
even greater for cardiac vascular imaging and other vascular imaging where multiple scans of the same anatomic section are required to produce four-dimensional and functional images |
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Increased frequency of adverse reactions of what? are found in patients with previous adverse reactions, asthmatics, diabetics, patients on -blockers or metformin, renal or cardiac failure, extremes of age, and patients with allergies or atopy.
27;299.2;p18 |
The most serious and fatal complication of IV contrast is the idiosyncratic anaphylactoid reaction. This reaction occurs without warning, cannot reliably be predicted, and is not currently preventable. anaphylactoid reactions are not dose dependent, and marked hypotension has been reported after a 1-mL IV test dose22 and death reported after a full dose was given subsequent to a negative test dose.
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It is generally recommended to give antihistamines and corticosteroids to patients who have a history of a previous anaphylactoid reaction to contrast media, multiple allergies, or asthma that is frequent or severe. Pretreatment reduces the risk by what factor?
27;299.2;p20 |
Pretreatment reduces the risk of reaction by a factor of 10 in some studies, but no regimen completely prevents adverse reactions.24 Most regimens in the literature recommend two to three doses of steroids starting at 12 to 18 hours before the administration of contrast, with the final dose given 1 to 2 hours before the contrast injection along with 50 milligrams of diphenhydramine.
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Patients with preexisting renal insufficiency, diabetic nephropathy, or who are taking nephrotoxic drugs (diuretics, NSAIDs, nephrotoxic antibiotics, cytotoxic therapies) are at increased risk for what?
27;299.2;p21 |
Well-hydrated individuals with normal renal function handle IV contrast material well, but those with abnormal renal function are at increased risk for contrast-induced nephropathy (CIN). A number of risk factors for CIN have
been identified, including chronic kidney disease, diabetes mellitus, congestive heart failure, older age, hypertension, anemia, hypotension, and left ventricular ejection fraction <40%. |
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Because this is renally excreted, patients with significant renal impairment may develop decreased excretion of
the drug after receiving contrast media. This accumulation of THIS may result in a potentially fatal lactic acidosis? 27;299.2;p22 |
Metformin is an oral biguanide that is used in type 2 diabetes mellitus for decreasing glucose production, decreasing intestinal absorption of glucose, and increasing insulin sensitivity. The FDA guideline advises that patients receiving IV contrast have their metformin held before or at the time of IV contrast administration for 48 hours, and only reinstituted after renal function is reassessed.
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A major limitation of head CT is imaging what?
27;299.2;p26 |
The posterior fossa. Because of the large difference in
beam attenuation between the dense bone of the skull and less dense brain tissue, "beam hardening" creates streaks that project across the brainstem and may obscure underlying tissue. |
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This concludes that there is a linear dose-response relationship between exposure to ionizing radiation and the development of solid cancers, and it is unlikely that
there is a threshold below which cancers are not induced. 27.299.2;p29 |
This report, BEIR VII (Biologic Effects of Ionizing Radiation), defines low doses as those in the range of up to 100 mSv (0.1 Sv). People in the U.S. are exposed to an average annual background radiation level of about 3 mSv. A chest x-ray delivers an exposure of about 0.1 mSv,
whereas exposure from a whole body CT scan is about 10 mSv. For example, the calculations predict that 1 individual in 1000 would develop cancer from an exposure to 10 mSv |
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Myocardial perfusion imaging allows the clinician to assess regional variations in myocardial blood
flow. How is this done? 27.299.1;p2 |
To do this, small amounts of radioactive tracer are injected IV, with images capturing the decay of these agents thereafter. Three radioactive tracers are in widespread use in the U.S.: thallium Tl 201 chloride, technetium Tc-99m sestamibi, and technetium Tc-99m tetrofosmin. Each of these agents is rapidly extracted from the circulation by cardiac myocytes, and, thus, the captured images reflect myocardial perfusion.
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When perfusion defects are identified, the nuclear cardiologist or radiologist can distinguish
regions of inducible ischemia how? 27;299.1;p3 |
inducible ischemia—a reversible defect that is likely secondary to flow-limiting coronary stenoses—from
fixed defects of prior infarction by comparing rest and stress images. Because myocardial perfusion imaging studies should become abnormal as soon as myocardial blood flow is impaired, this technique detects the presence of an acute coronary artery occlusion. |
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When used in the low-risk ED population, resting
myocardial perfusion imaging has been shown to have what sensitivity and what NPV? |
Myocardial perfusion imaging have both a high sensitivity and NPVs >99% for myocardial infarction. These studies, therefore, can quickly and accurately identify patients who are at low risk of adverse cardiovascular events—and thus safe for discharge—thereby avoiding many unnecessary hospitalizations.
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Studies suggest that single photon emission CT (SPECT)myocardial perfusion imaging has a sensitivity of 85% to 90% and specificity of 80% to 90% when compared with
what? 27;299.1;p4 |
Traditional coronary angiography. Because angiography remains the gold standard in many of these studies, however, there is a tendency to select for populations with more severe CAD. When used in patients with a high likelihood of disease, this referral bias may falsely elevate the sensitivity of these studies.
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When identified, these transient changes in regional function have BETTER OR WORSE? accuracy for detecting ischemia than ECG and patient symptoms?
27;299.1;p5 |
BETTER. Stress echocardiography is a well-studied and validated means for cardiac risk stratification. The use of this technology draws from long-standing evidence linking early coronary ischemia to focal wall motion abnormalities. There are several advantages of stress echocardiography as compared with SPECT myocardial perfusion imaging, including no radiation exposure to the patient or health care personnel, and no environmental impact.
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Four characteristic cardiac wall motion responses under stress give insight into the state of a patient's myocardial perfusion. What are the first 2? the second one is bolded.
27;299.1;p5 |
First, under normal conditions, the ventricular walls will move normally at rest, then continue to move normally or hyperdynamically during stress. Second, with inducible myocardial ischemia, walls will move normally at rest, but then develop transient focal dyskinesis, hypokinesis, or akinesis with stress.
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Four characteristic cardiac wall motion responses under stress give insight into the state of a patient's myocardial perfusion. What are the second 2? second one is bolded so this is FYI.
27;299.1;p5 |
Third, if focal wall abnormalities exist at rest, and these seem to improve upon the induction of stress, this suggests that the myocardium is viable, although it could be either stunned or jeopardized. Along similar lines, if these resting wall motion abnormalities improve at low doses of stress, then deteriorate at peak stress or during recovery, this is suggestive of viable, ischemic tissue. Last, if the myocardium is scarred and nonviable, there will be focal wall motion abnormalities at rest that are unchanged with stress.
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This modality has the potential to provide a less painful, more efficient, and safer alternative to this traditional modality?
27;299.1;p7 |
Coronary CT angiography (CCTA). Traditional angiography also offers the benefit of realtime
intervention, although some reports suggest that as many as 30% to 40% of conventional angiographic procedures are performed for diagnostic purposes only. And only for higher risk of CAD patients. Moreover, CCTA provides a wealth of concurrent information concerning other intrathoracic pathologies. |
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The radiation dose exposure reductions in modified MDCT, however, are substantial, approximately 70% to 80%, resulting in doses that are equivalent to traditional coronary angiography, and substantially less than SPECT myocardial perfusion imaging. What is the modification?
27;299.1;p11 |
MDCT with a prospective technique in which ECG gating allows pulsed doses of radiation during preselected phases of the cardiac cycle. This technique collects data only during user-defined intervals, typically mid-diastole or late systole because these are the periods with the least cardiac motion. Because the entire cardiac cycle is not captured with the prospective technique, it cannot be used to assess cardiac function.
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For this reason, patients with atrial fibrillation or frequent ectopy are typically precluded from evaluation with this technology?
27;299.1;p12 |
To minimize motion artifact, most centers recommend that patients have heart rates <65 beats/min, either at baseline or after the administration of IV or PO beta -blockers before the study. Second, because coronary CT requires ECG gating, significant arrhythmias (i.e., atrial
fibrillation, premature atrial contractions, and premature ventricular contractions) can lead to image degradation. Third, when evaluating for stenoses, coronary artery calcification can result in false positive and, rarely, false negative overestimations of flow-limiting narrowings. |
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The data also suggest that the accuracy of CCTA declines when used in patients with coronary stents or after coronary
artery bypass grafting. Accordingly, these studies may be inconclusive in patients with multiple coronary risk factors (diabetes, hypertension, older age, etc). So that means? 27;299.1;p13 |
Thus, in the setting of acute chest pain, CCTA has limited utility in this patient population. Finally, an IV contrast
allergy and pregnancy are absolute contraindications to CCTA, and caution should be taken in patients with baseline renal disease. |
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Cardiac MRI provides information on right and left systolic function (ventricular volumes, ejection fraction, and wall
motion abnormalities), allows for what? 27;299.1;p15 |
The identification of myocardial edema to suggest acute injury, evaluates myocardial perfusion both at rest and with pharmacologic stress, and detects infarction size and transmurality with delayed enhancement imaging.
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What are limitations of Cardiac MRI?
27;299.1;p16 |
Like all MRI, patients with pacemakers, defibrillators, cerebral aneurysm clips, metal in their eye, or cochlear implants are precluded from cardiac magnetic resonance. Patients who are claustrophobic may have difficulty completing these studies.
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When managing fractures with plates, why is it difficult to determine when fracture union is complete?
22;275.1;p2 |
the bones are often placed in direct contact, and healing usually occurs without the large amount of callus formation seen with casting or intramedullary nailing. Therefore, it is often difficult to determine when fracture union is complete, and it is not uncommon for the fracture line to be visible >1 year after surgery
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A more common complication of soft tissue– stabilizing implants is loss of fixation. Why is the diagnosis of a failed soft tissue-to-bone procedure is made clinically?
22;275.1;p30 |
Because radiographs are often normal, occasionally MRI is employed.
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If a patient with previous knee reconstruction presents to ER with an injury, what should you do?
22;275.1;p30 |
If surgery was performed <6 weeks previously, the knee examination also should be deferred to the treating orthopedist because the graft itself may not have fully healed to bone.
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Infection of a total joint arthroplasty is a catastrophic event. What should you do with this kind of patient that presents with intractable pain particularly with motion and possible wound drainage?
22;275.1;p54 |
Aspiration of the joint should be performed before administration of antibiotics, and the joint should not be aspirated without the surgeon's approval. It is possible for an aseptic implant to be infected by a needle aspiration.
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Are Arthroplasty infection is associated with systemic symptoms?
22;275.1;p54 |
Arthroplasty infection is rarely associated with systemic symptoms, and blood cultures are usually negative.
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What is the most common arthroplasty to dislocate?
22;275.1;p55 |
The Hip. Biplane radiographs confirm dislocation. Because these prostheses are often modular, great care should be used during relocation.
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What is normal compartment pressure?
22;275;p1881 |
<10 mm Hg. Pressures up to 20 mm Hg can be tolerated without significant damage. The exact level of pressure elevation that causes cell death is unclear and may be related to the length of time.
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Tissue Pressure exceeding 30-50 mmHg were traditionally thought to be toxic is untreated for several hours. But what is the RECENT THEORY?
22;275;p1881 |
There is data to support the theory that the difference between diastolic and the measured tissue pressure may be a better determinant. This is the delta pressure. Critical delta is 10-35 mmHg.
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When does pain usually start in compartment syndrome?
22;275;p1882 |
Typically starts within a few hours of the injury but develop up to 48 hours.
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How is compartment syndrome pain manifested?
22;275;p1882 |
By burning or dysesthesias in the sensory distribution of that nerve. Motor nerve function may also be impaired.
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What is the surgical remedy for compartment syndrome?
22;275;p1884 |
Fasciotomy should be performed as soon as the diagnosis is clinically confirmed or after the determination of elevated tissue pressure in relation to the diastolic blood pressure.
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What are the joints that separate regions of the foot?
22;274;p1875 |
Chopart separates the hindfoot, Lisfranc joint divides the midfoot and the forefoot.
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What is the most commonly fractured tarsal bone?
22;274;p1876 |
Calcaneus. Whereas the talus is infrequently fractured.
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When the is a fracture in the hind foot why are there usually associated injuries?
22;274;p1876 |
These injuries required large force, like an axial load to heel.
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What is needed radiographically for a hindfoot fracture?
22;274;p1876 |
Boehler angle of <25 degrees. Which is the intersection on lateral view of calcaneus with first line between anterior and posterior calcaneal articulating surface and second line of posterior calcaneal surface to the most superior part of calcaneal tuberosity.
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Why are major talar fractures, including the head and neck of talus, considered potential surgical emergencies?
22;274;p1876 |
A high rate of AVN can occur with these injuries.
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What other talus injuries are considered potential surgical emergencies?
22;274;p1876 |
Dislocations of the talus are rare.
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Pain elicited by torsion of the midfoot raise suspicion of what?
22;274;p1877 |
Lisfranc Fracture. Also, injuries about the tarso-MT joint, with pain on passive dorsi or plantarflexion of the foot, should warrant evaluatioooooon of Lisfranc injury.
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Xrays for possible Lisfranc injury?
22;274;p1877 |
Weightbearing AP and 30 degree obliques. Bony displacement of 1 mm or greater between the bases of the first and second metatarsals is considered unstable.
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Displaced Lisfranc injuries are managed how?
22;274;p1877 |
Displaced lisfranc injuries are by definition unstable and need anatomic reduction.
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Proximal fractures of the shaft of the first through fourth metatarsals are typically caused by a crush injury and what other injury should be ruled out?
22;274;p1878 |
Lisfrance injury is crucial to rule out.
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What displacement and or angulation usually requires surgical reduction in metatarsal fractures?
22;274;p1878 |
3-4mm of displacement or >10 degrees requires surgery usually.
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Which joints meed to be examined need to be examined for an ankle injury?
22;273;p1867 |
Joint above and below the ankle.
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What type of fracture should suspected with tenderness of fibular head or proximal fibular shaft?
22;273;p1867 |
Maisonneuve fracture (or fibulatibialis ligament tear)
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The recent use of flouroquinolones and corticosterioids increase the risk of what injury?
22;273;p1868 |
Achilles' tendon. the Thompson test should be performed if there is d=tenderness or a defect. Palpate the hindfoot and midfoot over the calcaneus, tarsals, and base of the fifth metatarsal to check for areas of tenderness that may require further investigation.
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On an ankle injury, an inability to dorsiflex the toes suggests what?
22;273;p1869 |
a tibial nerve injury. Inability to plantar flex the great toe is suspicious for peroneal injury.
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Ottwa Ankle Rules for ankle and midfoot.
figure 273-4- 22;273;p1869 |
Xrays are required only if there is pain the malleolar zone or midfoot zone along with bony tenderness in any of four zones or inability to bear weight both immediated and in the ED.
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If there is significant medial malleolus tenderness and swelling, what fracture should be suspected?
22;273;p1869 |
a Maisonneuve fracture of the proximal fibula and fibular shaft. negative xrays should lead you to suspect syndesmosis tears.
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What are the most common ankle dislocations?
22;273;p1871 |
Posterior dislocations. They occur with a backward force on the plantarflexed foot, usually resulting in rupture of the tibiofibular ligaments or a lateral malleolus fracture.
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What is evident by a dusky foot or absent pulses, or tenting of the skin in a ankle dislocation?
22;273;p1871 |
Vascular compromise. An immediate reduction by the emergency physician is warranted without any prereduction radiographs.
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Except for fibular avulsion fractures, all ankle fractures require immobilization by cast or surgical repair and casting. Fibular fractures are instead treated as stable ankkle sprains when minimally displaced at what level?
22;273;p1874 |
<3 mm of displacement and no signs of medial ligamentous injury.
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What is the most important prognostic factor in open ankle fractures?
22;273;p1874 |
Amount of energy involved.
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Assuming no allergies, the open ankle patient should receive what?
22;273;p1874 |
Prophylactic antibiotics, most commonly cefazolin with the addition of an aminoglycoside if there is gross contamination of the wound.
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What is the most commonly fractured long bone?
22;272;p1865 |
The tibia. The grading fracture system is the Gustillo.
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Acceptable reduction parameters of tibial fracture are?
22;272;p1865 |
50 percent or more of cortical contact, <10-15 degrees of angulation on lateral film, <10 on AP, <5 of rotational deformity.
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What may increase the risk of compartment syndrome?
22;272;p1865 |
Tight fitting splint or casts. Tibial fractures sometime require a long leg splint from high above the knee at 6 degrees of flexion and foot slight plantar flexed
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What the heck is a pilon fracture?
22;272;p1866 |
Axial force on foot driving the talus into tibia crushing the distal tibia. Also called a tibial plafond fracture
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Pilon fractures may be accompanied by what else?
22;272;p1866 |
Compartment syndrome or by vertbral body fractures, particularly a fracture of the first lumbar vertabrae.
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A distal tibia growth plate fracture(triplanefx) cause by rotational force can look like a Salter Harris 3 on AP and SH2 on lateral. What should be done next?
22;272;p1866 |
CT scan, which often can reveal further deformity of the articular surface.
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What is meant by a proximal fibula fracture?
22;2272;p1866 |
Proximal is relative; the fibula may be fractured at its head or as far down as 6 cm above the ankle joint(weber C ankle fracture)
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Where is the Achilles most frequently ruptured?
22;272;p1867 |
The achilles vascular supply is weakest in the area 2-6 cm above the calcaneus.
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What are risk factors ruptured Achilles?
22;272;p1867 |
1. Older age
2. Prior quinolone use 3. Prior steroid injection |
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What else should be examined when examining a an injured knee?
22;272;p1857 |
The uninjured knee for comparison, esppecially during palpation and stress testing.
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What knee rules are useful in evaluating a injured knee?
22;271;p1857 |
Ottawa Knee-sensitive in identifying fractures. The Pittsburg Knee Rules-similiar but may have higher specificity
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What radiographic finding suggests intra-articular fracture and may be identified on a lateral view of the knee?
22;271;p1858 |
FAt-fluid levels (lipohemarthrosis)
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What is most useful in detecting nondisplaced vertical or marginal fractures of the patella?
22;271;p1858 |
Sunrise(skyline, axial, tangential). It is indicated if patellar subluxation or fracture is suspected.
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What type of patellar fractures are more likely to be dispaced and to be associated with a disrupted extensor mechanism?
22;271;p1858 |
Tansverse patellar fractures.
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Fractures of the femoral condyles have this potential and needs further testing?
22;271;p1858 |
The potential for popliteal artery injury so the status of distal sensation and pulses need checked. The space between first and second toes, innervated by the deep peroneal nerve, should be tested for sensation.
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What ligamentous injuries are associated with lateral plateau fractures?
22;271;p1859 |
Anterior cruciate and medial collateral ligament
injuries are associated with lateral plateau fractures, whereas posterior cruciate and lateral collateral ligament injuries occur with medial plateau fractures. |
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When compared to the uninjured knee, what level of laxity is considered complete rupture of medial or lateral collateral ligament?
22;271;p1860 |
>1cm laxity without a firm end point- in varus and valgus stress
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What degree of laxity in lachmanns and anterior drawer is indicative of a ACL tear?
22;271;p1860 |
Lachmann is >5mm and is 84% specific versus Anterior drawer is >6mm which is 62% specific
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What percentage os all hemarthrosis are caused by ACL disruption?
22;271;p1861 |
75%- so most knee ligamentous injuries present with hemarthrosis
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What should patient do daily when in knee immobilizers?
22;271;p1861 |
Daily ROM exercises to avoid contractures and maintain mobility.
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In Athrocentesis, presence of blood and glistening fat globules is pathognomonic of what?
22;271;p1861 |
Lipohemarthrosis, which indicates intra-articular knee fracture.
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What is the most common knee dislocation?
22;271;p1862 |
An anterior dislocation is most common, occurring about 40% of the time, with posterior dislocations (33%), lateral dislocations (18%), medial dislocations (4%), and rotary dislocations also occuring. 50% spontaneously reduce.
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What complications have a high incidence with knee dislocations?
22;271;p1862 |
Popliteal artery injury, peroneal nerve injury (mostly posterolateral dislocations) in addition to ligamentous and meniscal injury.
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Because of high incidence of popliteal artery injury(up to one-third) and poor outcomes from delayed treatment, what do some authors recommend?
22;271;p1862 |
Arteriography for all knee dislocations.
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In a knee knee dislocation, does normal distal pulses rule out popliteal artery injury?
22;271;p1862 |
NO. splint in 20 degrees of flexion- imaging should be considered
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How do you reduce a patellar dislocation?
22;271;p1863 |
Reduction is accomplished with the patient under conscious sedation by flexing the hip, hyperextending the knee, and sliding the patella back into place.
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What radiographic finding may be found with quad or patellar tendon rupture?
22;271;p1863 |
A high-riding patella on lateral xray. treatment is surgical repair within 7 -10 days
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With penetrating knee injury, taking history should include what?
22;271;p1864 |
Information to re-create the knee position during the penetrating injury
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Those who have been immobile for a prolonged period due to their inability to send for help should also be evaluated for what?
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evaluated for dehydration or rhabdo
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Significant hip pain w/ weight bearing in the face of nml radiographs should raise suspicion for
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occult fracture, especially at the femoral neck or acetabulum
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Judet views or thin-cut CT scans are often recommended for further evaluation of what?
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Judet views or thin-cut CT scans are often recommended for further evaluation of the acetabulum and fracture fragmentation of femoral head fracture
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The number of attempts at closed reduction of femoral head fracture in the ED should be?
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Limited
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Femoral neck fracture are most commonly caused by falls in what population?
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among older osteoporotic women
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Patients with non-displaced femoral neck fracture may be ambulatory whereas those with displaced fracture will be unable to what ?
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Bear weight
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Disruption of Shenton’s line, a smooth curvilinear line along the superior border of the obturator foramen and medial aspect of the femoral metaphysic, may be appreciated on the
|
the AP view in some instances of femoral neck fracture; Figure 270-5
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This is contraindicated with femoral neck fracture because it may further compromise femoral head blood flow
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Skeletal Traction
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Blood loss into the leg can be significant in intertrochanteric and subtrochanteric fracture and some pt will require what?
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crystalloid or blood transfusion
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Hip dislocation should be reduced within how many hours because delays in reduction correspond with a higher incidence of avascular necrosis?
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Hip dislocation should be reduced within 6 hrs
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What percentage of hip dislocations are posterior
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90%
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Treatment of posterior hip dislocation without fracture is what?
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hip dislocation without fracture is closed reduction, under procedural sedation or general anesthesia, as quickly as possible and within 6 hrs
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Traction splints are indicated or contraindicated in cases of open femur fracture with grossly contaminated exposed bone ends or when sciatic nerve injury is probable?
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Traction splints are contraindicated
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What requires broad-spectrum abx and copious irrigation?
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Open Femur fracture requires broad-spectrum abx and copious irrigation. Further irrigation and debridement are accomplished in surgery.
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If clinical suspicion is present for stress fracture of the femoral neck in a high-risk patient (runners and football players), what test should be done?
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MRI or bone scan should be considered.
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Which dislocations have a prominent medial clavicle end that is visible and palpable anterior to the sternum?
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Anterior dislocations
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Patients with uncomplicated anterior dislocations may be discharged with what?
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Patients with uncomplicated anterior dislocations may be discharged without an attempted reduction, as this injury has little or no impact upon function
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Posterior dislocations may be associated with life-threatening injuries to include?
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Posterior shoulder dislocations may be associated with life-threatening injuries to adjacent structures, including pneumothorax or compression or laceration of surrounding great vessels, trachea, or esophagus
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Distal clavicle fracture with displacement are often associated with what?
|
Distal clavicle fracture with displacement are often associated with rupture of the coracoclavicular ligament, and may require operative intervention to avoid nonunion
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Medial clavicle injuries can be associated with what?
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Medial clavicle injuries can be associated with intrathoracic injuries
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Due to the high energy typically required to fracture the scapula, there is a high association with what?
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Due to the high energy typically required to fracture the scapula, there is a high association (>75%) of injuries t o the ipsilateral lung, thoracic cage, and shoulder girdle, with fracture of the ribs most common
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What percentage of patient with scapulothoracic dissociation (MVA or life-threatening fall) have vascular injury, with the subclavian or axillary arteries most commonly involved?
|
90% of patient with scapulothoracic dissociation have vascular injury, with the subclavian or axillary arteries most commonly involved
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Treatment of type I and II ACJ injuries consists of what?
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Treatment of type I and II ACJ injuries consists of rest, ice analgesics, and immobilization followed by early ROM exercises (7-14 days)
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Most experts recommend what for type IV-VI ACJ injuries ?
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Most experts recommend surgical repair of type IV-VI ACJ injuries (severe)
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Anterior dislocation of what joint are the most common major joint dislocations?
|
Anterior dislocation of the glenohumeral joint are the most common major joint dislocations
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Most common neurovascular injury in anterior glenohumeral joint dislocations occurs to what nerve?
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Most common neurovascular injury in anterior glenohumeral joint dislocations occurs to the axillary nerve (assess sensation over deltoid)
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Shoulder dislocations or subluxations combined with what type of fracture generally require ortho consult and may need operative repair?
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Shoulder dislocations or subluxations combined with proximal humerus fracture generally require ortho consult and may need operative repair
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Most common complication of shoulder dislocation is what?
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Most common complication of shoulder dislocation is recurrence
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Vascular injuries are rare with shoulder dislocations but most often involve the what vessel in elderly patients?
|
shoulder dislocations but most often involve the axillary artery in elderly patients
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In shoulder dislocation, most commonly include what type of bony injury?
|
Bony injuries are common in shoulder dislocation and most commonly include compression fracture of the humeral head (Hill-sachs lesion) and anterior glenoid lip (bankhart lesion)
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A frequent but often missed injury with shoulder dislocation is what?
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A frequent but often missed injury with shoulder dislocation is tear of the rotator cuff
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Carefully perform the neurovascular exam in suspected humerus fracture why?
|
perform the neurovascular exam in suspected humerus fracture as the brachial plexus and axillary arteries are near the coracoids process and can be injured
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A “one-part” fracture of the humerus is define as what?
|
A “one-part” fracture of the humerus is one in which the fragments are displaced < 1 cm or not at all, or is not angulated > 45 degrees. This can involve multiple fragment and still be termed “one-part”
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Treatment for a “one-part” proximal humerus fracture generall consists of what?
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immobilization (sling and swathe), ice, analgesics, and ortho referral (all other proximal humerus fractures require ortho consult in the ED)
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What is a common site of pathologic fracture, especially from metastatic breast cancer.
|
Humerus is a common site of pathologic fracture, especially from metastatic breast cancer.
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A simple sling an swathe are adequate for the emergency management of most closed humeral shaft fractures? true or false
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true
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Complications of humeral shaft fracture may include what?
|
Complications of humeral shaft fracture may include injury to the brachial artery or vein or radial, ulnar, or median nerve injury.
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A radial nerve injury, which is the most common in humeral shaft fracture, may be manifested by what findings?
|
A radial nerve injury may be manifested by a wrist drop and altered sensation at the dorsal thumb index web space
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Adduction and internal rotation of the shoulder indicates weakness of muscles and nerves?
|
Adduction and internal rotation of the shoulder indicates weakness of the deltoid and infraspinatus muscles (C5), whereas elbow extension Is due to weakness of the biceps (C6), and flexion of the digits and wrists is due to weakness of the extensors (C7)
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The single best test of radial nerve motor function is?
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to have the patient extend both the wrist and fingers against resistance
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A simple test of anterior interosseous nerve (branch of median) is what?
|
A simple test of anterior interosseous nerve (branch of median) is the ability to make a circle, or OK sign with the thumb and index finger. Abduction of the thumb against resistance (recurrent branch of median nerve)and intact two point discrimination over the tip of the index finger complete the eval of the median nerve
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Two easy tests of ulnar nerve function are what?
|
Two easy tests of ulnar nerve function are the ability to abduct the index finger against resistance and two-point discrimination over the tip of the fifth digit
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Flexion of the elbow, best accomplished how?
|
Flexion of the elbow, best accomplished with the arm abducted and externally rotated, will elicit pain and may produce a midarm “ball”, which represents the distally retracted biceps muscle.
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Ability to extend the elbow is lost with what type of tendon rupture?
|
Ability to extend the elbow is lost with complete triceps tendon rupture
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A “terrible triad” elbow injury describes an unstable joint consisting of what?
|
A “terrible triad” injury describes an unstable joint consisting of an elbow dislocation coupled with fractures of the radial head and coronoid
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What percentage of all elbow dislocations are posterlateral?
|
Approximately 90% of all elbow dislocations are posterlateral
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The first priority of care with elbow dislocation is what?
|
elbow dislocation: to assess the neurovascular status of structures most vulnerable to entrapment, namely the brachial artery and the ulnar, radial, and median nerves
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With injury, fat from the olecranon fossa is displaced posteriorly (posterior fat pad), and the anterior fat pad may become quite prominentand known as what?
|
Sail Sign due to hemarthrosis. May be only sign of fracture and treatment is initiated as though fracture were identified
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Displaced fractures must be treated how?
|
Displaced fractures must be reduced and require emergent ortho consult
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Posteromedial displacement of supracondylar fracture may involve which nerves?
|
Posteromedial displacement of supracondylar fracture may involve the radial nerve, and posterolateral displacement usually affects the median nerve
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A high incidence has been noted of anterior interosseous nerve injuries with what fracture?
|
A high incidence has been noted of anterior interosseous nerve injuries with supracondylar fracture
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Why is the identification of the elbow injury can be made only by motor testing, which consist of flexion at the index finger distal interphalangeal?
|
because there is no sensory component to the anterior interosseous nerve, identification fo the injury can be made only by motor testing, which consist of flexion at the index finger distal interphalangeal - OK sign
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|
the most serious complication of supracondylar fracture is what?
|
the most serious complication of supracondylar fracture is a compartment syndrome toe the forearm, also known as Volkmann ischemic contracture
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|
It is well understood that the mere lack of a radial pulse does indicate or does not ischemia? unless accompanied by refusal to open the hand in children, pain with passive extension of the fingers, and forearm tenderness (impending Volkmann ischemia)
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Does not
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What fractures are the most common fracture of the elbow?
|
Radial head fractures are the most common fracture of the elbow
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Associated injuries with radial head fracture are common and may include what?
|
may include capitellum, olecranon, and coronoid fracture, medial collateral ligament injury, medial epicondyle avulsion fracture secondary to valgus stress, and elbow dislocation
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|
Recognizing the development of a compartment syndrome is particularly important to prevent what?
|
To prevent debilitating ischemic or Volkmann contractures of the forearm
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|
Isolated ulna fracture most often the result of what?
|
Isolated ulna fracture most often the result of direct blow (nightstick fracture)
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Fracture with >50% displacement, >10% angulation, or those that involve the proximal third of the ulna are considered what?
|
Unstable?
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|
Monteggia fracture-dislocation is what?
|
Monteggia fracture-dislocation; fracture of prox third of the ulna with a radial head dislocation. Missing the radial head dislocation can lead to chronic pain, limited ROM, and possible radial head excision as Treatment
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|
Galeazzi Fracture-dislocation is what?
|
Galeazzi Fracture-dislocation; fracture of the distal third of the radial shaft with dislocation of the distal radioulnar joint. Also referred to as “reverse Monteggia”
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What is the site of disruption in perilunate and lunate dislocations?
|
The space of Poirier is on the volar aspect of the wrist and is inherently weak.
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Who are more likely to sustain injuries to the immature, weaker epiphyseal plate or metaphysic of the radius, sparing the still cartilaginous carpal bones
|
Children are more likelyto sustain injuries to the immature, weaker epiphyseal plate or metaphysic of the radius
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In the elderly, more so in women due to increased incidence of osteoporosis, what is the weak point in their wrists?
|
the weak point is the brittle distal radial metaphysic, resulting in a Colles fracture, often with intra-articular involvement
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|
what is the “anatomic snuff box”?
|
The scaphoid is palpable within the triangle formed by the bony radial styloid at its proximal base, the extensor pollicis brevis tendon at its radial aspect, and the extensor pollicis longus tendon t its ulnar aspect
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The scaphoid is normally palmar-flexed on the lateral view; its axis should from an angle of what?
|
The scaphoid axis should from an angle between 30 and 60 degrees with the lunate
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|
What is the most common fracture in the wrist?
|
Fracture of the distal radius; alteration of the normal volar tilt of 10 to 15 degrees of the distal radial articular surface has greater long-term consequences for wrist function
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|
What is the most commonly injured ligament of the wrist?
|
The scapholunate ligament has a marked propensity for injury and is the most commonly injured ligament of the wrist
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|
Scapholunate dissociation is defined as what?
|
Scapholunate dissociation is a widening of the scapholunate joint space of >3mm on the PA view (carpals are normally separated from each other by 1-2mm)
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|
ED Treatment of scapholunate ligament injury consists of what?
|
ED Treatment of scapholunate ligament injury is a radial gutter splint or short arm volar posterior mold with ortho referral
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The perilunate dislocation is best appreciated on what X-ray view?
|
The perilunate dislocation is best appreciated on the lateral view. The linear arrangement of the three C’s sign is disrupted with the capitates, represented by the third C, displaced dorsal to the lunate. The lunate retains its contact with the radius.
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|
|
what is “spilled teacup” sign?
|
The lunate (represented by the middle C) is pushed off the radius into the palm. This has been called the “spilled teacup” sign because it resembles a cup spilling in the direction of the palm
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All patients with perilunate or lunate dislocations require emergency ortho consultation because complications include what?
|
Perilunate or lunate dislocations complications include development of carpal instability patterns that lead to early degenerative arthritis, delayed union, malunion, nonunion, avascular necrosis, and occasionally median nerve compression from the volar dislocation of the lunate into the carpal tunnel
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A scaphoid fracture can develop avascular necrosis of the proximal fracture segment that can lead to what?
|
A scaphoid fracture can develop avascular necrosis of the proximal fracture segment that can lead to disabling arthritis
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Up to what percent of initial radiographs fail to detect a scaphoid fracture?
|
Up to 10% so initial Treatment should be directed by clinical suspicion. Non-displaced fracture and those that are only clinically suspected can be treated in a short-arm thumb spica splint
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|
The dorsal avulsion fracture of the triquetrum is best seen on the what X-ray?
|
The dorsal avulsion fracture of the triquetrum is best seen on the lateral radiograph or an oblique view in partial pronation
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|
The lunate’s blood supply enters through the distal end of the bone. A fracture subjects the lunate to risk for AVN of the proximal portion known as ?
|
AVN of the proximal portion (Kienbock disease)
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|
|
Displaced fracture of trapezium what size?
|
Displaced fracture of trapezium >1mm or diastasis >2mm require surgery
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|
Standard and carpal tunnel views are necessary to visualize fracture involving what part?
|
Standard and carpal tunnel views are necessary to visualize fracture involving the hook of the hamate. Occult fracture may be identified by bone scan ror CT
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|
|
What is a Colles Fracture?
|
Colles Fracture; wrist has the characteristic dorsiflexion, or “dinner-fork,” deformity. In general, unstable fractures have >20 degrees of angulation, intra-articular involvement, marked comminution, or more than 1cm of shortening.
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|
What is a Smith Fracture?
|
Smith Fracture; “reverse Colles fracture”; lateral xray shows the volar angulated and displaced fracture
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|
|
What is a Barton Fracture;
|
PA xray often shows a comminuted fracture fo the distal radial metaphysic. Lateral view reveals an intra-articular fracture of the volar or dorsal rim of the radius, which may be accompanied by carpal subluxation in the same direction.
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|
|
Treatment for Unstable Barton Fracture?
|
Unstable fracture involving >50%of the radial articular surface or those with accompanying carpal subluxation require open reduction and internal fixation
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|
In distal radioulnar joint disruption the lateral radiograph demonstrates what?
|
In distal radioulnar joint disruption the lateral radiograph demonstrates either volar or dorsal displacement of the ulna, which is normally centered and overlapping the radius
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|
The adductor pollicis is innervated by what nerve?
|
The adductor pollicis is innervated by the ulnar nerve
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|
The palm is often referred to as “no man’s land” due to what?
|
The palm is often referred to as “no man’s land” due to difficulty evaluating and treating penetrating injuries
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|
Injuries with the digits in flexion may result in retraction of the cut end of the tendon when the digit is examined in what position?
|
Neutral Position
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|
To test the median nerve, have the patient do what?
|
Have the patient flex the distal phalanx of the thumb against resistance. Patient will also not be able to oppose against resistance if median nerve function is lost
|
|
|
Ulnar nerve integrity can be assessed by what?
|
Ulnar nerve integrity can be assessed by having the patient spread the fingers apart against resistance and then push them together against resistance
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|
To examine the radial nerve do what?
|
To examine the radial nerve, extend the fingers and wrist. With the tumb in the hitchhiking position, test its resistance to further extension
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|
|
Normal two-point discrimination is what measurement?
|
Normal two-point discrimination is <6mm at the fingertips and is often <2mm. Both injured and noninjured fingers must be compared
|
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|
Up to what percentage of a tendon can be lacerated with preservation of range of motion without resistance?
|
Up to 90% of a tendon can be lacerated with preservation of range of motion without resistance.
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|
Pain along the course of the tendon during resistance testing suggests what?
|
Pain along the course of the tendon during resistance testing suggests a partial laceration even if strength appears adequate.
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|
Do not leave finger tourniquet in place longer than?
|
20 minutes
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|
Most hand specialists prefer to do definitive repair within when?
|
Most hand specialists prefer to do definitive repair within 3 to 5 days of the acute injury
|
|
|
What is Mallet Finger?
|
Disruption of the extensor tendon at the DIPJ will result in the joint remaining flexed 40 degrees; referred to as “mallet finger” and is the most common tendon injury in athletes; untreated this may result in a “swan neck” deformity due to increased tension at the PIPJ
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|
Complete disruption of the central extensor tendon of the PIPJ may lead to what?
|
Volar displacement of lateral bands causing extension of the MCPJ and DIPJ, resulting in the boutonniere deformity
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|
Tendon lacerations of < 25% do or do not require repair?
|
Tendon lacerations of < 25% do not require repair; 25-50% require simple suture; > 50% requires specialized repair
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|
Irreducible dislocations of the DIPJ may be due to what?
|
Irreducible dislocations of the DIPJ may be due to entrapment of an avulsion fracture, the profundus tendon, or volar plate
|
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|
If PIPJ is irreducible or there is evidence of complete ligamentous disruption, what is required?
|
Operative repair
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|
|
Reduction of MCPJ dislocation is performed how?
|
Reduction of MCPJ dislocation is performed by flexing the wrist ot relax the flexor tendon and then applying pressure over the dorsum of the proximal phalanx in a distal and volar direction
|
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|
Reduction of dorsal CMC joint dislocations can be attempted after what?
|
Reduction of dorsal CMC joint dislocations can be attempted after regional anesthesia. Traction and flexion with simultaneous longitudinal pressure on the metacarpal base should reestablish normal anatomic alignment
|
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Hand surgery referral is recommended for all patients with weakness of pincer function and point tenderness at the volar-ulnar aspect of the thumb MCPJ why?
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It is an injury resulting from a forced abduction MOI (gamekeeper’s thumb/skier/s thumb) or more than 40 degrees radial angulation (complete rupture)
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Angulation of < 20 degrees in the fourth and 40 degrees in the fifth metacarpal will or will not result in functional impairment?
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Angulation of < 20 degrees in the fourth and 40 degrees in the fifth metacarpal will not result in functional impairment. If greater angulation in these metacarpals occurs, reduction should be attempted.
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What is a Bennett fracture?
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Bennett fracture – associated subluxation or dislocation at the CMCJ; thumb spica and surgical referral
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What is a Rolando fracture?
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Rolando – comminuted fracture at base of metacarpal; thumb spica and surgical consult
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Hand compartment syndromes may or may not be associated with paresthias?
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Hand compartment syndromes may not be associated with paresthias, and the extremely subtle motor deficits and difficulty in assessing response to passive stretch make the dx more elusive than at other anatomic sites
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Definitive Treatment of high-pressure injection injuries is what?
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Early surgical decompression and debridement of injected areas (amputation rates following injection injury area as high as 30%)
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What are Salter Harris Fractures?
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Salter (Epiphyseal Plate) – involve the physis of long bones of growing children
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The term “open fracture” means?
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The term “open fracture” applies to any puncture wound extending to the depth of an underlying fracture
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What are 3 types of Fractures?
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1. “Common” – direct trauma to healthy bone
2. Pathologic – Minor trauma to diseased or otherwise abnormal bone 3. Stress – “fatigue” fracture |
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Although this infection may sometimes be unavoidable, it becomes less likely when treatment is prompt and meticulous?
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oeteomyelitis
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Dislocation of the what? also carries the potential for avascular necrosis of the femoral head (dislocation disrupts blood flow)
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HIP
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Any injury associated with neurologic or vascular compromise should be addressed when?
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As soon as possible (may only require traction)
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Effective splinting does what 3 things?
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1. Reduces pain
2. Reduces damage to nerves and vessels 3. Prevents converting a closed fracture to an open fracture |
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Optimal immobilization includes the joint above and what?
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Optimal immobilization includes the joint above and below the fracture
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If an inflatable splint cannot be dented by moderate thumb pressure, it is probably what?
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If an inflatable splint cannot be dented by moderate thumb pressure, it is probably overinflated
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The pain of a fracture or dislocation may or may not be referred to another area?
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It may be deferred
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Imaging decisions should be based not only on the chief complaint, but also on what?
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Also on systematic palpation, observation of subtle deformity or significant point tenderness, and mechanism of injury.
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Some injuries might not be radiographically apparent on the first day regardless of what views are taken. True or False?
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True- I'm too lazy to change the question
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Timely Treatment of a fracture may depend solely on what?
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Timely Treatment of a fracture may depend solely on a clinical index of suspicion
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Knowing what? may be the key to diagnosing some fractures or dislocations
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Knowing the precise mechanism of injury may be the key to diagnosing some fractures or dislocations
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Some musculoskeletal injuries or conditions may not necessarily be associated with a hx of direct trauma. True or False?
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True
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Exquisite tenderness to palpation or pain on weightbearing or passive range of motion suggests what?
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Exquisite tenderness to palpation or pain on weightbearing or passive range of motion suggests the possibility of an occult or easily missed fracture
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A general medical history should be obtained because it may have what?
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A general medical hx should be obtained because it may have implications for further workup, the potential for complications, or ultimate prognosis for recovery of function.
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The joints above and below a fracture should generally be imaged because why?
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The joints above and below a fracture should generally be imaged because injury at the proximal or distal joint may coexist with long-bone fracture
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Shortening is used for what?
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A fracture needs to be visualized at an angle 90 degrees from the first to differentiate it from a fracture whose ends are completely displaced and overriding
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If there is a possibility of ambiguity in the description, specifying the direction of deviation of the distal fragment this can usually can resolve it?
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Angulation
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Which Salter fractures may be radiographically undetectable?
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Type 1 and 5 Salter fractures may be radiographically undetectable
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Even narcotic analgesics have virtually no effect on the pain of movement or manipulation unless combined with what?
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other central nervous system-acting agents
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When deformity is associated with circulatory deficit, what exists?
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When deformity is associated with circulatory deficit, a true emergency exists, and the anticipated delay until reduction should be considered
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effective such therapy may be in preventing infection in open fracture?
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The longer the interval the less effectiveness
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Antibiotics alone can or cannot be relied on the prevent infection in the absence of adequate irrigation and debridement?
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Cannot. Both of which have been demonstrated to be crucial to reducing the infection rate in open fracture by reducing bacterial contamination and the potential for bacterial colonization
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Indications for ortho consult in the ED?
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1.Compartment syndrome
2. Irreducible dislocation 3. Circulatory compromise 4. Open fracture 5. Injuries requiring surgical intervention |
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What splints should not be used for fractures of the wrist or carpals (reproduces position of injury)?
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Cock up splints
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Patients wearing a knee immobilizer should remove the device periodically to do what?
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To perform passive flexion and quad strengthening exercises
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Although simple in principle, determining spinal stability after an acute injury is particularly what?
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Although simple in principle, determining spinal stability after an acute injury is particularly difficult
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Vertebral body compressions of level of injury are generally considered unstable?
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Vertebral body compressions of >25% for the third to seventh cervical vertebrae or >50% in the thoracic or lumbar vertebrae from an acute injury are generally considered unstable
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Any patient with neuro deficits or radiographic evidence of injury should be considered to have what?
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An unstable injury
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Atlanto-occipital injuries are considered?
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Atlanto-occipital injuries are extrememly unstable
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What is a Jefferson Fracture?
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C1 (Atlas) fracture, burst fracture due to axial load. If displacement of both lateral masses (measured as offset from the superior corner of the C2 vertebral body on each side) is >7mm when added together, rupture of the transverse ligament is likely, and the spine is unstable
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A predental space of >3mm on a lateral xray (2mm for CT) implies damage to to what?
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A predental space of >3mm on a lateral xray (2mm for CT) implies damage to the transverse ligament; >5mm implies rupture of the transverse ligament
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What is a Hangman’s Fracture?
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C2 (Axis) fracture, “Hangman’s Fracture”, aka traumatic spondylolisthesis of the Axis1
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What is a clay-shoveler’s fracture?
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Spinous process avulsion fracture, classically C7, is known as a clay-shoveler’s fracture
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Patients with blunt chest trauma and mediastinal widening should be evaluated for what 2 things?
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both aortic and thoracic spine injuries
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Why are isolated fractures of the lower lumbar spine rarely injure the spinal cord or result in neurologic injury?
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Because of the width of the spinal canal in the lumbar region and the ending of the spinal cord at the L1 level
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Fracture-dislocations are the most what?
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Fracture-dislocations are the most damaging of injuries
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Sacral fractures that involve the central sacral canal can produce what?
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Sacral fractures that involve the central sacral canal can produce bowel or bladder dysfunction
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A complete neurologic lesion is defined ?
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A complete neurologic lesion is defined as the absence of sensory and motor function below the level of injury
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An incomplete neurologic lesion is present if what exists?
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An incomplete neurologic lesion is present if sensory, motor, or both functions are partially present below the neurologic level of injury
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Patients in spinal shock lose all reflex activities below the area of injury, and lesions cannot be deemed complete until what?
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Lesions cannot be deemed complete until spinal shock has resolved
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Three most important spinal tracts in terms of neuroanatomic localization of cord lesion are?
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1. Corticospinal tract
2. Spinothalamic tract 3. Dorsal columns |
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Corticospinal tract is described as what?
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Corticospinal tract – descending motor pathway; injury results in ipsilateral upper motor neuron sxs such as weakness, spasticity, & increased DTRs
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Spinothalamic tract is described as what?
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Spinothalamic tract – ascending sensory pathway; transmits pain and temp; injury results in loss of pain and temp sensation in the contralateral side
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Dorsal columns are described as what?
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Dorsal columns – ascending sensory pathway; transmit vibration and proprioceptive information; injury results in Ipsilateral loss of vibration and position sense
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In Dorsal column injury is Light touch lost ?
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Light touch is not completely lost unless injury to both the spinothalamic tract and dorsal columns
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What is Anterior cord syndrome?
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Manifested by loss of motor function and pain and temp sensation distal to the lesion. Only vibration, position, and crude touch are preserved
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What is Central cord syndrome?
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Present with decreased strength and, to a lesser degree, decreased pain and temp sensation, more in the upper than the lower extremities
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What is Brown-Sequard syndrome?
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Hemisection of the cord; presents with ipsilateral loss of motor function, proprioception, and vibratory sensation, and contralateral loss of pain and temp sensation (best prognosis of the incomplete spinal cord syndromes)
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What is Cauda Equina syndrome?
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Peripheral nerve injury rather than cord injury; presents with variable motor and sensory loss in the lower extremities, sciatica, bowel and bladder dysfunction, and “saddle anesthesia”; peripheral nerves regenerate therefore better prognosis than cord lesion
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How does Cauda Equina syndrome present?
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Presents with variable motor and sensory loss in the lower extremities, sciatica, bowel and bladder dysfunction, and “saddle anesthesia”; peripheral nerves regenerate therefore better prognosis than cord lesion
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Patients with neurogenic shock are usually what?
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Patients with neurogenic shock are warm, peripherally vasodilated, and hypotensive with relative bradycardia
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Hypotension in the trauma patient can never be presumed to be caused by neurogenic shock until what?
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until other possible sources of hypotension have been excluded; blood loss until proven otherwise
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If IV fluids are not adequate to maintain organ perfusion, what else can be used
|
positive inotropic pressor agents may be beneficial adjuncts to improve cardiac output and raise perfusion pressure
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What is Spinal shock?
|
Spinal shock refers to the temporary loss or depression of spinal reflex activity that occurs below a complete or incomplete spinal cord injury and is not synonymous with neurogenic shock
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Any patient with an injury at what level or above should have their airway secured via endotracheal intubation?
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Any patient with an injury at C5 or above (phrenic nerve emerges from C3-C5)
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Anogenital reflexes should also be tested because?
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“sacral sparing” with preservation of the reflexes denotes an incomplete spinal cord level, even if the patient has complete sensory and motor loss
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NEXUS criteria to rule out need for C-spine imaging; must meet all five- is what?
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1. No midline cervical tenderness
2. Nml level of alertness and consciousness 3. No evidence of intoxication 4. No focal neurologic deficit 5. No painful distracting injury |
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This is more sensitive and specific than plain radiography for evaluating the cervical spine in trauma patients, and can be performed in a more expeditious fashion
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Cat Scan
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The current trend in most trauma centers is to use Cat Scan as what?
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The initial imaging modality to evaluate the cervical spine, and CT scanning is the imaging modality of choice for suspected cervical spine fractures
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The determination of a spinal column injury at one level should prompt imaging of the remainder of the spine; approximately what percentage of patients with a spine fracture in one segment will have a second fracture at another?
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10%
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Patients should be moved off the backboard onto the gurney mattress. True or False?
|
True. The standard hospital mattress provides adequate spinal support
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What is the test of choice for describing the anatomy of nerve injury?
|
Entities such as herniated disks or spinal cord contusions can also be delineated on MRI.
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What medication remains a controversial treatment in acute blunt spinal cord injury?
|
High-dose methylprednisolone remains a controversial treatment in acute blunt spinal cord injury
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What is an indication for urgent surgery
|
Progressive neurologic deterioration is an indication for urgent surgery
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Numbness, paresthesias, or “shock-like” sensations in the extremities are suggestive of what?
|
SCIWORA (spinal cord injury without radiologic abnormality) and should be expeditiously evaluated for evidence of spinal cord injury; MRI is indicated; more common in young children
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This is particularly useful to visualize those portions of the cervical spine that are commonly missed?
|
CT. and frequently injured in children such as the occipitoatlantal and cervicothoracic junctions
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What best assesses spinal cord, disk, and ligamentous disruption?
|
MRI can also detect soft tissue injury and hematoma not visualized by other imaging modalities
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Most common causes of rhabdomyolysis in adults are what?
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1 alcohol and drugs of abuse,
2. medications, 3.muscle diseases, 4.trauma, 5. neuroleptic malignant syndrome, 6. seizures, 7. then immobility, infection, strenuous physical activity and heat-related illness |
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What is the most frequently cited infectious cause and Legionella is the most frequently reported bacterial cause?
|
Influenza
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What is the most sensitive and reliable indicator of muscle injury
|
Elevated serum CK level is the most sensitive and reliable indicator of muscle injury
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Most investigators consider a what or greater increase above the upper threshold of normal in serum CK level, in the absence of cardiac or brain injury, as the requirement for the diagnosis of rhabdomyolysis
|
5 fold
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Qualitative tests such as the dipstick test (which uses the orthotoluidine reaction) do not differentiate among hemoglobin, myoglobin, and red blood cells. Why?
|
Because myoglobin contains heme. Therefore myoglobinuria should be suspected when the urine dipstick test is positive for blood, but no red blood cells are present on microscopic examination.
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What is the most important Treatment in preventing acute renal failure?
|
Early and vigorous IV fluid resuscitation. Potassium or lactate containing solutions should not be given. Aggressive IV rehydration should be continued for the first 24 to 72 hrs
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Procedural sedation is what?
|
The administration of sedatives or dissociative anesthetics to induce a depressed level of consciousness while maintaining cardiorespiratory function
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What are the Levels of sedation?
|
1. Minimal (anxiolysis),
2. Moderate (“conscious sedation”), 3. Deep 4. General. |
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Key principle of sedation is?
|
Lightest appropriate level should be used (complications increase with deeper levels) and plan for deeper levels than intended (depth can not always be predicted)
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What level sedation is characterized by anxiolysis but with normal arousal to verbal stimuli (midazolam, fentanyl, low-dose ketamine)
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Minimal
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What level of sedation with propofol, ketamine, or combination fentanyl and midazolam?
|
Moderate sedation. Dissociative sedation is a type of moderate sedation.
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Deep sedation with same agents as what sedation but larger doses?
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Moderate
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The complication rate of Procedural Sedation and Analgesia is primarily determined by what?
|
Primarily determined by the interaction of the depth of sedation and the patient’s current medical condition
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A potentially difficult airway should be anticipated when the following findings or conditions are present?
|
short neck, micrognathia, large tongue, trismus, morbid obesity, a hx of difficult intubation, or anatomic anomalies of the airway and neck
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|
what are the Fasting states?
|
1. Nothing >3hrs, low risk
2. Clear liquid <3 hrs, higher risk but acceptable for any level of sedation 3. Light snack < 3hrs, limit to mod sedation 4. Meal <3hrs, urgent – moderate sedation, non-urgent – light sedation |
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What medications is commonly used as a sole agent for minimal sedation?
|
Midazolam
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Slow administration of fentanyl (1-2mcg/kg over 5 min) followed by slow and careful flushing of the IV line can prevent what?
|
Rigid chest syndrome (rare complication but RSI usually required if it occurs)
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Ketamine has what properties unlike other PSA agent?
|
Ketamine has both analgesic and anxiolytic properties unlike other PSA agents. Also preserves ventilator effort and has minimal effect on BP.
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What should be corrected prior to propofol administration (neg inotrope and vasodilator)?
|
Hypovolemia. Allergy precaution with propofol (egg and soy). Initial dose should be 50% of adult dose in elderly pts with more cautious titration (resp depression and apnea)
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Is it possible to generalize the extent and quality of pain control needed for a specific patient?
|
No. It is not possible. Specific measure need to be taken to address pain in addition to treating underlying illness or injury.
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There is good or bad correlation between nonverbal signs (tachycardia, facial expression) and patient’s report of pain so do not rely on these?
|
Poor correlation, so do not rely on these. A value assigned by a patient on a pain scale is not an absolute value but rather a reference point based on past personal experience. Reassess.
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|
The purpose of the pain scales is to what?
|
Quantitate pain severity, use the quantitative measures to select and administer the appropriate type of analgesic agent, and reassess the pain response to determine the need for repeated doses or more effective analgesics.
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When there are language difficulties or cross-cultural differences, what is the preferred pain assessment modality?
|
The VAS (visual analog scale) is the preferred pain assessment modality because it is the least affected by these factors
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The keys to effective pharmacologic pain management in the ED are what?
|
The selection of an agent appropriate for the intensity of pain, prompt onset of analgesic activity, ease of administration, safety, and efficacy.
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|
The “tiered approach” for acute pain management unnecessarily subjects the patient to what?
|
More prolonged suffering. It is preferable to select initial analgesics that are appropriate to treat the intensity (mild, mod, severe) of the patient’s pain. (review Tables 38-3,4,5,10,11)
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|
What are the cornerstone of pharmacologic management of mod to severe acute pain?
|
Opioid analgesics. Needs to be titrated to effect and rarely requires adjuncts.
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|
At most what percentage of patients are at risk for prescription medication abuse?
|
At most only 10%.
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Until more is known, it would be prudent to switch to a drug from a different opioid class if what occurs?
|
If a patient develops a hypersensitivity reaction to an opiate (Table 38-7)
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Is use of codeine recommended?
|
Use of codeine not recommended (increased GI side effects, 10% of population can’t metabolize it to active component, not more effective than Tylenol/motrin)
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|
What is drug of choice in trauma?
|
Fentanyl (minimal impact on hemodynamics), Opioids are an alternate (not primary) for migraine, do not withhold in abdominal pain
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|
At discharge patients should be counseled on what regarding pain medication?
|
To take subsequent doses on a regular basis or when their pain begins to return rather than when it peaks. Also give activity restriction while medicated (driving, etc) and Treatment of constipation for opioids
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